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CHICAGO -- Guidelines are one thing. Reality is another, researchers here suggested.

The American College of Rheumatology (ACR) and the European League Against Rheumatism recommend routine measurement of rheumatoid arthritis (RA) disease activity and the adjustment of drug therapy in patients to attain remission or low-disease activity.

At an ACR press conference as part of the group's annual meeting, Jeffrey R. Curtis, MD, MPH, a rheumatologist, epidemiologist and informaticist at the University of Alabama at Birmingham, discussed a study measuring the extent to which RA patients switched to more aggressive therapies in search of improvement and remission over a one-year period.

Curtis and colleagues extracted data about nearly 51,000 patients with RA in RISE (Rheumatology Informatics System for Effectiveness), a clinical database compiled by ACR. Patients had to be adults with RA who had one or more rheumatologist visits with an accesible disease activity measure in 2016.

The goal was to see if rheumatologists practice what they preach in terms of recommended "treat-to-target" strategies, Curtis said.

They don't: Nearly 50% of patients in the study did not undergo treatment changes despite treat-to-target guidelines that should have prompted aggressive changes.

"I was delighted it wasn't worse. Clearly, we have a long way to go," Curtis said.

He said the study did not explore the reasons from doctors and patients on why changes were not made.

'Clinical Inertia'

Curtis speculated that many patients and doctors in the RA area seem to be satisfied with "good-enough" care and not demanding the best care possible, with the result being a quality-of-care gap in rheumatology.

He called this gap in RA care "clinical inertia" and suggested that it would be unacceptable in oncology.

"These findings shine a spotlight on the relatively high proportion of patients who fail to change RA therapies despite not achieving the treat-to-target goals of low disease activity or remission," said Curtis. "While a number of explanations might be offered, including limitations of the current RA measurement tools, and some patients being on maximal medical therapy -- for example, methotrexate, biologics or low-dose glucocorticoids -- this finding is concerning. It suggests that multi-touch, multi-modal interventions are needed to encourage clinicians and patients to strive to improve RA disease control and use the available RA therapies in a more aggressive fashion, thereby leading to better outcomes."

Curtis noted that his study involved data from electronic medical records. One problem, he said, was that these records often are missing important data that could and should be collected, and he stressed that improvement without measurable data is impossible.

He said many clinicians complain they are too busy to collect data or the process is too complicated. Still, he found this "quite encouraging because what that means is they're not averse to doing the measurement and to having it and having systems [collect and analyze data] be they electronic or otherwise. You just have to make it easy enough. It's a feasibility thing," said Curtis.

On the patient side, he said many patients are fearful of changing to more aggressive treatment because they see the laundry list of side effects from new meds advertised on TV. "Patient refusal is actually a big deal, and patients are voting with their feet. You know, 'Doc, I'm good enough, I'm better enough, I'm happy enough because I'm afraid that this new medicine may give me lymphoma or an infection or I'll die.'"

Meeting Treat-to-Target's Potential

Cianna Leatherwood, MD, now a rheumatologist at Kaiser Permanente's Oakland Medical Center, told the press conference that treat-to-target studies can successfully result in patients optimize drug care.

She and colleagues at Brigham and Women's Hospital and Harvard Medical School's rheumatology clinic in Boston used treat-to-target to optimize medicine in RA patients. Researchers calculated disease activity scores, collecting data directly from patients using iPad tablets in the waiting room and an online patient portal. This was a non-randomized, quality improvement study of 2,549 patients with RA who completed a survey over a year ending in May 2018.

Rheumatologists were assigned to either an intervention or control group.

Researchers retroactively identified patients patients whose medication changed to calculate a treatment-to-target score. Data generation by patients earned buy-in for the study among clinical staff.

Preliminary data showed that the scores were more than 12% higher in the intervention group compared with controls.

Leatherwood said that electronic patient and real-time integration of survey scores in EMRs enhanced treat-to-target results in patients with RA.

"We hope that our experience can exemplify that it is possible to pursue routine implementation of patient-reported outcome measures into daily clinical practice," she said.